Upper Motor Neuron and Spasticity

["Management of spasticity in children 239 Spira, R. (1971). Management of spasticity in cerebral Walsh, E. G. (1988). Assessment of human hemiplegic spas- palsied children by peripheral nerve block with phenol. ticity by a resonant frequency method. Clin Biomech, 3: Dev Med Child Neurol, 13: 164\u201373. 173\u20138. Staheli, L. T., Duncan, W. R. & Schaefer, E. (1968). Growth Waterman, P. M., Albin, M. S. & Smith, R. B. (1980). Malignant alterations in the hemiplegic child. Clin Orthop, 60: 205\u2013 hyperthermia: a case report. Anesth Analg, 59: 220\u20131. 12. Wei, S., Su-Juan, W., Yuan-Gui, L. et al. (2006). Reliability Stanley, F. J. & Alberman, E. (1984). The Epidemiology of the and validity of the GMFM-66 in 0 to 3 year old children Cerebral Palsies. Philadelphia: J. B. Lippincott. with cerebral palsy. Am J Phys Med Rehab, 85: 141\u20137. Stefko, R. M., De Swart, R. J., Dodgin, D. A. et al. (1998). Kine- Wilkinson, S. P., Portman, B. & Williams, R. (1979). Hepatitis matic and kinetic analysis of distal derotation osteotomy from dantrolene sodium. Gut, 20: 33\u20136. of the leg in children with cerebral palsy. J Paediatr Orthop, 18: 81\u20137. Wright, F. V., Sheil, E. M. H., Drake, J. M., Wedge, J. H. & Nau- mann, S. (1988). Evaluation of selective dorsal rhizotomy Steinbok, P., Reiner, A. M., Beauchamp, R. et al. (1997). A for the reduction of spasticity in cerebral palsy: a random- randomized clinical trial to compare selective posterior ized control trial. Dev Med Child Neurol, 40: 239\u201347. rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy. Dev Med Young, R. R. & Delwaide, P. J. (1981a). Drug therapy: spastic- Child Neurol, 39: 178\u201384. ity (\ufb01rst of two parts). N Engl J Med, 304: 28\u201333. Stoffel, A. (1913). The treatment of spastic contractures. Am Young, R. R. & Delwaide, P. J. (1981b). Drug therapy: J Orthop Surg, 10: 611\u201344. spasticity (second of two parts). N Engl J Med, 304: 96\u20139. Tardieu, G., Centaur, S. & Delarue, R. (1954). A la recherche d\u2019une technique de mesure de la spasticite \u2018imprime\u2019 avec Zieglgansberger, W., Howe, J. R. & Sutor, B. (1988). The neu- le periodique. Rev Neurol, 91: 143\u20134. ropharmacology of baclofen. In: Muller, H., Zierski, J. & Penn, R. D. (eds.), Local-Spinal Therapy of Spasticity. New Utili, R., Boitnott, J. K. & Zimmerman, H. J. (1977). York: Springer-Verlag, pp. 37\u201349. Dantrolene-associated hepatic injury: incidence and character. Gastroenterology, 72: 610\u201316. Ziv, I., Blackburn, N., Rang, M. & Koreska, J. (1984). Muscle growth in normal and spastic mice. Dev Med Child Neurol, Van Schaeybroeck P., Nuttin, B., Lagae, L. et al. (2000). 26: 941\u201384. Intrathecal baclofen for intractable cerebral palsy spasticity: a prospective placebo-controlled, double- RECOMMENDED READING blind study. Neurosurgery, 46: 603\u201312. Dormans, J. P. & Pellegrino, L. (eds.). (1998). Caring for Chil- VanWinkle, W. B. (1976). Calcium release from skeletal mus- dren with Cerebral Palsy: A Team Approach. Baltimore: cle sarcoplasmic reticulum: site of action of dantrolene Paul H. Brookes. sodium? Science, 193: 1130\u20131. Miller, G. & Clark, G. D. (eds.). (1988). The Cerebral Vaughan, C. L., Berman, B. & Peacock, W. J. (1988). Gait anal- Palsies: Causes, Consequences and Management. Boston: ysis of spastic children before and after selective lumbar Butterworth-Heinemann. rhizotomy. Paediatr Neurosci, 14: 297\u2013300. Sussman, M. D. (ed.). (1992). The Diplegic Child. Rosemont, Vaughan, C. L., Berman, B. & Peacock, W. J. (1991). Cerebral IL: American Academy of Orthopaedic Surgeons. palsy and rhizotomy. A three year follow-up and evalua- tion with gait analysis. J Neurosurg, 74: 178\u201384.","","Index ablative procedures, 193\u2013203, 209 Achilles tendon, surgical lengthening of, 218 active function, antispastic agents and, 131 active stiffness, de\ufb01nition of, 79 activities of daily living, 4 scale of, 134 activity limitations de\ufb01nition of, 79 physiotherapy interventions, 86\u20137 spasticity as determinant of, 80\u20131 activity timed walking test, 133, 134 adductors, hip, motor point injections of, 158 age factors. See also pediatric spasticity effect on spasticity, 82\u20134, 228 agonist\/antagonist co-contractions, 3\u20134 Aircast ankle stirrup, 121, 122 alcohol intramuscular wash, 157\u20138 pharmacology, 152\u20133 side effects of, 160 alcohol nerve blocks, 7 dosage and concentration, 159\u201360 indications, 132\u20133 intrathecal, 161\u20132, 202\u20133 pediatric use of, 223\u20134 therapeutic effects of, 159 alignment effect of muscle overactivity and length on, 89\u201390 orthotic correction of, 114 alpha motoneurone excitability electrophysiologic studies of, 47\u20138, 49 measurement of, 49 animal studies. See also speci\ufb01c animal age factors affecting spasticity, 84 botulinum toxin, 226\u20137 241","242 Index animal studies (cont.) diagnostic use of, 33 contractures, 81 pathophysiology of, 33, 34 \ufb02exor re\ufb02ex afferents, 28\u201330 axon terminals, sprouting of, 15 motor pathways, 10 tonic stretch re\ufb02exes, 20\u20131, 24\u20135 Babinski sign. See extensor plantar response backrest, in seating system, 102\u20133 ankle brace, 121, 122 baclofen, 135\u20138 ankle clonus antinociceptive effects of, 181\u20132 medial popliteal nerve blocks for, 151\u20132 chemical structure, 135\u20136 pathophysiology of, 17 clinical ef\ufb01cacy, 136\u20137 ankle dorsi\ufb02exion, in children, 215, 217\u201319 in combined modality therapy, 92 ankle foot orthosis (AFO), 121\u20134 versus diazepam, 139 aim of, 114 dosage and administration, 137 assessment for, 117 in drug combinations, 133 design of, 116, 121\u20132, 123 indications, 132\u20133 dynamic, 122\u20133 intrathecal. See intrathecal baclofen (ITB) ground reaction, 123, 124 mechanism of action, 136, 222\u20133 hinged, 123, 124 overdosage, 190 pediatric use of, 223 pediatric use of, 221, 222\u20133 types of, 122\u20134 pharmacology, 136, 181\u20132, 222\u20133 ankle planta\ufb02exion side effects, 137\u20138, 222\u20133 orthotic correction of, 115\u201316 Barthel ADL Index, 134 pathophysiology of, 25\u20136 Becker intelligent knee ankle foot orthosis, 124, 126 ankle stirrups, 118, 121, 122 benzodiazepines, 138\u20139. See also speci\ufb01c drug anterior horn cell excitability, effects of intrathecal in drug combinations, 133 mechanism of action, 138 baclofen on, 183 biofeedback, in seating support, 105 antibody formation, botulinum toxin, 166, biological clock, in cerebral palsy, 84, 215 biomechanical approaches 169\u201370 equinus assessment, 89\u201390 antispastic agents, 7. See also pharmacological therapy; orthoses, 115\u201316, 117, 118 spasticity measurement, 71\u20134, 76 speci\ufb01c drug versus chemical neurolysis, 150 in children, 219 combined use of, 133 indirect, 73\u20134, 76 contraindications to, 131 birthday syndrome, 93 dose titration, 133 bladder control loss, after intrathecal blocks, 162 electrophysiologic monitoring of, 39, 52, 53 blood\u2013brain barrier, intrathecal baclofen and, 182 indications, 132\u20133, 135 Bobath concept of normal movement, 113 pediatric use of, 221\u20133 body suits, 113 selection of, 131 BOTOX\u00ae, 166, 168, 169, 171, 173, 176, 230 anxiety, in children with spasticity, 222 botulinum toxin (BoNT-A), 7, 165 arm. See upper limb advantages of, 176 arthrodesis, 209 adverse effects of, 166, 170, 176 Ashworth scales, 65\u20136, 69 clinical trials, 172\u20134, 227\u201330 hypertonia measured with, 81 in combined modality therapy, 171\u20132, 176, 215, 223, 231\u20132 level of measurement, 66\u20137 commercial formulations, 166\u20137, 176, 230 pediatric use of, 217 cost of, 170\u20131 recommendations, 68\u20139, 76 delay in onset of clinical effects, 166 reliability of, 67\u20138 dilution, 168 versus Tardieu scale, 85 associated reactions, 3\u20134, 33\u20134 botulinum toxin for, 175\u20136","Index 243 dosage, 168\u20139, 230 casting, 119\u201320 in drug combinations, 133 age factors affecting, 84 guidelines for use, 168 botulinum toxin combined with, 171 immunoresistance, 166, 169\u201370 in children, 223, 229\u201330 indications, 132\u20133, 174\u20136, 184, 231 de\ufb01nition of, 113 injection technique, 168\u20139, 228 serial. See serial casting versus intrathecal baclofen, 184 long-term ef\ufb01cacy and safety of, 169\u201370 cat mechanism of action, 165, 167 alpha motoneurone excitability in, 47\u20138 orthoses combined with, 118, 125 decerebrate. See decerebrate cat model pediatric use, 174, 215, 219, 223, 224, 226\u20137, 229, 232 extension responses in, 32 pharmacology, 165\u20137 \ufb02exor re\ufb02ex afferents in, 28 spasticity assessment prior to, 167\u20138 \ufb02exor withdrawal re\ufb02exes in, 30, 31 therapeutic effect of, 167, 169\u201370 Ib nonreciprocal inhibition in, 43 for upper limb spasticity, 152, 228\u20139 positive support reaction in, 38 botulinum toxin (BoNT-A) clinics, 176 recurrent inhibition in, 45 botulinum toxin type A (BoNT-A), 165 clinical trials, 172\u20134 catheterization, for intrathecal baclofen, 185, 187, in combined modality therapy, 92, 93 189 commercial formulations, 166, 176 cost of, 170\u20131 central alpha-2 adrenergic receptor agonists, 141\u20133. See dilution, 168 also clonidine; tizanidine dosage, 168\u20139 for equinus gait, 91\u20132 central nervous system, plasticity of, 15 immunoresistance, 166, 169\u201370 cerebellar stimulation, 184, 193 versus muscle lengthening techniques, 91 cerebral lesions, spasticity caused by, versus spinal cord botulinum toxin type B (BoNT-B), 165 commercial formulations, 166\u20137, 176 lesions, 14\u201315 immunoresistance, 166, 169\u201370 cerebral palsy. See also pediatric spasticity botulinum toxin type C, 165 botulinum toxin type F, 165, 166 biological clock in, 84, 215 bowel control loss, after intrathecal blocks, 162 muscle growth in, 215, 220, 225 brachial plexus neurotomies, 196\u20137 outcome measures, 220 bracing, functional, to prevent muscle stiffness, 89 seating concerns. See seating brainstem areas cerebrospinal \ufb02uid, intrathecal baclofen in, 182 controlling spinal re\ufb02exes, 11, 12, 14 cerebrospinal \ufb02uid leakage, from ITB pumps, 190 motor pathways descending from, 12, 13 cervical orthoses, 125\u20136, 127 bulbar problems, 4 Cesament. See nabilone bulbospinal motor pathways, in associated reactions, chemical neurolysis, 150. See also motor point injections; 34 nerve blocks bupivacaine, 152 in children, 223\u20134 in combined modality therapy, 150\u20131 calf shortening, dynamic, 214 complications of, 160 calf spasticity, in children, 215, 223 diagnostic use of, 152 cannabis, 135, 143\u20134 dosage and concentration, 159\u201360 caregivers goals of, 151 indications for, 150, 151 education of, 5 versus oral antispastic agents, 150 quality of life assessment, 135 procedures, 153\u20139 stress prevention, 5 therapeutic effects of, 159 children. See cerebral palsy; pediatric spasticity chlorocresol, 152, 153 clasp-knife phenomenon, 16, 21, 22, 23 clawed hand, botulinum toxin for, 175 clonazepam, 136, 139","244 Index cortico-reticular drive, 14 cost clonidine, 141\u20132 clinical ef\ufb01cacy, 142 botulinum toxin, 170\u20131 mechanism of action, 13, 141 intrathecal baclofen, 183 pharmacokinetics, 141 crawling, surgical management and, clonus, 1\u20132 209\u201311 ankle, 17, 151\u20132 cresol, 152 induction of, 17 crossed extensor re\ufb02ex, 28, 32 pathophysiology of, 17 crouch gait, orthotic treatment of, 123 cushions, seat, 107 clorazepate, 139 custom moulded seating, 109 co-contraction, 34\u20135 cutaneous re\ufb02exes, 16, 28. See also speci\ufb01c re\ufb02ex versus hyperactive stretch re\ufb02ex, 35, 36 Dantrium. See dantrolene sodium pathophysiology of, 34\u20135, 43 dantrolene sodium, 139\u201341 coerulospinal tract, 13 collars, cervical, 125\u20136, 127 clinical ef\ufb01cacy, 136, 140 collateral sprouting, 15 dosage and administration, 140 combined modality therapy in drug combinations, 133 botulinum toxin in, 171\u20132, 176, 215, 223, 231\u20132 indications, 132\u20133, 222 chemical neurolysis in, 150\u20131 mechanism of action, 139\u201340, 222 for children with spasticity, 221, 224, 233\u20134 pediatric use of, 221, 222 intrathecal baclofen in, 189 pharmacokinetics, 140, 222 orthoses in, 113, 223 side effects, 141, 222 pharmacological agents in, 131 decerebrate cat model, 10 physiotherapy in, 92\u20133 \ufb02exor re\ufb02exes in, 28 positioning in, 99\u2013100 group II afferents in, 50 surgical management in, 200, 201 stretch re\ufb02ex hyperexcitability in, 24\u20135 communication, dif\ufb01culty with, 4 tonic vibration re\ufb02ex in, 50 con\ufb01dence factor, 118 decorticate posture. See hemiplegic posture contoured seating, 109 deep brain stimulation, 193 contractures deep tendon re\ufb02ex, 16 age factors affecting, 84 delta-9-tetrahydroccabinol (THC), 143\u20134 botulinum toxin for, 91\u20132 descending motor pathways characteristic features of, 2\u20133, 214 pathophysiology of, 10\u201311, 12 in children, 214, 215\u201317 in spinal cord, 12, 13\u201314 dynamic, 214, 215\u201317 dexterity, loss of, 4 \ufb01xed, 215\u201317, 218\u201319 diazepam, 138\u20139 myostatic, 214, 218\u201319 versus baclofen, 139 pathophysiology of, 27\u20138, 81 clinical ef\ufb01cacy, 136, 138\u20139 prevention of dosage and administration, 139 indications, 222 casting, 119\u201320 pediatric use, 221\u20132 orthoses, 114\u201315 pharmacology, 138, 221\u20132 physiotherapy, 89\u201390, 91 rebound phenomenon, 222 stretching, 2, 101 side effects, 139, 221\u20132 stretch re\ufb02ex hyperexcitability and, 25 diplegia, contracture prevention in, 215\u201317 surgical release of, 7 disability, global scales of, 135 Cordis Secor pump, 190 dorsal reticulospinal tract, 13\u201314 cortical control \ufb02exor re\ufb02exes inhibited by, 28, 29 of excitatory area, 12 of inhibitory centre, 11 of motor function, 10\u201311","Index 245 dorsal rhizotomy. See selective dorsal rhizotomy excitatory system, 11\u201313, 14 (SDR) effect of inhibitory drive reduction on, 14\u201315 electrophysiologic studies of, 47\u20138, 51 dorsal root entry zone (DREZ), surgery in, 203\u20134, 205\u20136, 207, 208, 209 extensor plantar response, 31\u20132 evocation of, 31 Dr Berrhill jacket, 127, 128 dronabinol, 143 extensor re\ufb02exes, 32\u20133 dynamic ankle foot orthoses, 122\u20133 extensor spasms, 32\u20133 dynamic contractures, 214, 215\u201317 dynamic insoles, 114, 118, 122\u20133 characteristic features of, 3 dynamic range of motion testing, in children, 217\u201319 functional advantage of, 33 dynamic seating, 107, 109 dysaesthesiae, neurolytic agent-induced, 160 \ufb01xed contractures, in children, 215\u201317, 218\u201319 Dysport\u00ae, 166, 168\u20139, 173, 176, 230 \ufb02accid foot, orthotic correction of, 115\u201316 dystonia, 3, 35\u20138 \ufb02exion re\ufb02ex excitability, effects of intrathecal baclofen on, de\ufb01nition of, 35\u20137, 79 182 effect of stretching on, 37 \ufb02exor re\ufb02ex, 23 management of, 37\u20138 \ufb02exor re\ufb02ex afferents (FRAs), 28\u20139, 30 elbow extension, loss of, 217\u201319 electrophysiologic studies of, 50\u20131 elbow \ufb02exors, static tonic stretch re\ufb02exes in, 22, 23 supraspinal control of, 28\u20139, 30, 32 electrical stimulation \ufb02exor spasms, 30\u20131 characteristic features of, 3 botulinum toxin combined with, 171, 172 pathophysiology of, 13, 14, 15 nerve blocks using, 153\u20134 \ufb02exor withdrawal re\ufb02exes, 30 electromyography (EMG) demonstration of, 30, 31 for botulinum injection guidance, 169 \ufb02u-like symptoms, botulinum toxin-related, 170 intraoperative, 200 focal techniques, 7 in spasticity assessment, 84 foot deformities electrophysiologic studies, 39 functional electrical stimulation for, 128\u20139 correlation with clinical signs, 39, 52, 75\u20136 medial popliteal nerve blocks for, 151\u20132 drug monitoring using, 39, 52, 53 orthotic correction of, 115\u201316 excitatory system, 47\u20138, 51 tibial neurotomy for, 197, 199 H re\ufb02exes, 38\u201340 footplates. See insoles Ia presynaptic inhibition, 40\u20132 footwear. See shoes Ia reciprocal inhibition, 42, 43 functional electrical stimulation (FES), 128\u20139 Ib nonreciprocal inhibition, 43\u20134, 45 Functional Independence Measure (FIM), 183 of recurrent inhibition, 45\u20136, 47 Functional Mobility Scale, 220 spinal inhibitory mechanisms, 38 functional posterior rhizotomy, 200 spinal re\ufb02exes, 38 functional sitting position, 104 epidural spinal stimulator implants, 184 fusimotor drive theory, 24\u20135, 28 equinus F waves, 49, 75, 183 assessment of, biomechanical approaches to, gabapentin, 144 89\u201390 gait botulinum toxin A for, 91\u20132, 229\u201330 management of, 223, 229, 230 ankle dorsi\ufb02exion during, 215, 217\u201319 medial popliteal nerve blocks for, 151\u20132 ankle planta\ufb02exion during ergonomics, seating systems and, 106 ethyl alcohol. See alcohol orthotic correction of, 115\u201316 excitatory interneurone hyperexcitability, pathophysiology of, 25\u20136 crouch, orthotic treatment of, 123 electrophysiologic studies of, 49 dif\ufb01culty with, 4 modulation of stretch re\ufb02exes during, 24","246 Index gait (cont.) hip deformities, obturator nerve blocks for, 152 nonreciprocal inhibition during, 43\u20135 hip \ufb02exion spasticity, botulinum toxin for, 175 scissoring, obturator nerve blocks for, 152 hip \ufb02exors, motor point injections, 158\u20139 surgical management and, 209\u201311 hip integrity, seating and, 101\u20132, 103, 120\u20131 hip knee ankle foot orthosis (HKAFO), 124 gait analysis, 73\u20134, 76 hip orthoses, 124 in children, 219 hip surgery, proper positioning after, 102 in drug monitoring, 134 Hmax\/Mmax ratio, 49, 75 in orthotic assessment, 114, 117, 129 horseback riding posture, 106 H re\ufb02ex(es), 17 \u2425 -amino butyric acid (GABA), 181 gastrocnemius-soleus diagnostic use of, 75 electrophysiological studies of, 38\u201340 motor point injections of, 151\u20132, 158 reciprocal inhibition of, 43 re\ufb02ex contraction induced in, 17 vibratory inhibition of, 40\u20131 shortening of, 217\u201318 H-re\ufb02ex amplitudes, 49 spasticity in, knee casting for, 223 H-re\ufb02ex conditioning technique, 45 gate control theory of pain, 193 H-re\ufb02ex recovery curves, 51 general anesthesia, prior to botulinum toxin injection, 169, hygiene, hand orthoses and, 128 hygiene scale, 134 227\u20138 hyperre\ufb02exia, de\ufb01nition of, 79 global scales of disability, 135 hypertonia Golgi tendon organs, role in clasp-knife phenomenon, 21, age factors and, 84 assessment of, 82, 84\u20135 23 biomechanical components of, 2\u20133, 25\u20137, 28, 82, 84\u20135 goniometry, 135 de\ufb01nition of, 64, 79 grasp dynamometer testing, 134 measurement of, 81 Gross Motor Function Classi\ufb01cation System neural component of, 2\u20133, 26, 27, 82, 84\u20135 versus spasticity, 81 (GMFCS), 220 hypotonia, seating and, 99 Gross Motor Function Measure (GMFM), 220 hysteresis loop, 72 ground reaction ankle foot orthosis, 123, 124 group II afferents, role in spasticity, 23 group II polysynaptic excitatory pathways, electrophysiologic studies of, 50\u20131 guided injection techniques, for botulinum toxin, 169 hamstrings Ia polysynaptic excitatory pathways, electrophysiologic botulinum toxin injections to, 230 studies of, 49\u201350 neurotomy at, 196 stretching of, in seating support, 101 Ia presynaptic inhibition, electrophysiologic studies of, 40\u20132 Ia reciprocal inhibition hand deformities botulinum toxin for, 175 electrophysiologic studies of, 42, 43 peripheral neurotomies for, 197\u20138 impairment of, co-contraction caused by, 34\u20135, 43 Ib nonreciprocal (autogenic) inhibition, electrophysiologic hand orthoses, 127\u20138 hemiplegia studies of, 43\u20134, 45 immobilization contracture prevention in, 215\u201317 movement therapy for, 88\u20139 age factors affecting, 84 hemiplegic posture, 3, 33, 35 effect on muscle length and stiffness, 26\u20137, 90 pathophysiology of, 34, 37 immunoresistance, to botulinum toxin, 166, 169\u201370 hemiplegic shoulder impairment, de\ufb01nition of, 79 botulinum toxin for, 175, 228\u20139 infants, seating systems for, 108\u20139 orthotic management of, 126\u20137, 128 infection hinged ankle foot orthoses, 123, 124 at ITB pump implants, 190 hip abduction orthoses, seating support with, 102 at site of nerve block injection, 160 hip adductors, motor point injections of, 158 Infusaid pumps, 190 inhibitory system, 11, 14","disruption of, 14\u201315 Index 247 insoles, 121 assessment for, 117 dynamic, 114, 118, 122\u20133 intelligent, 124, 126 International Standards Organization knee block, seating support with, 102, 103, 106, 109 knee casting, for gastrosoleus spasticity, 223 orthosis de\ufb01nition, 113 knee hyperextension, orthotic correction of, 116, 118, 119, seating standards, 108 inter(intra)-rater reliability 123\u20134, 125 Ashworth scales, 67\u20138 knee locks, 124 Tardieu method, 70, 71, 85, 86 knee orthoses, 123\u20134 intrathecal baclofen (ITB), 7, 181 alternatives to, 184 Lance, J. W., de\ufb01nition of spasticity, 9, 79 versus botulinum toxin, 184 lateral vestibular nucleus, 12\u201313 in cerebrospinal \ufb02uid, 182 leg. See lower limb in combined modality therapy, 189 limb garments, 113 complications of, 189\u201390 Lioresal. See baclofen cost\u2013bene\ufb01t analysis, 183 local anaesthetics, diagnostic use, 152 dose\u2013response relationship, 181 locus coeruleus, 13 effects on function and quality of life, 183 longitudinal myelotomy, 203 excretion of, 182 long-latency response (LLR), 50\u20131 indications, 184, 209 loss of dexterity, 4 localization of, 182 lower extremity telescopic orthosis (LETHOR), 117 neurophysiological effects of, 182\u20133 lower limb, peripheral neurotomies in, 194\u20135, 196, 197, overdosage, 190 patient selection, 183\u20135 199 pediatric use, 188\u20139, 222\u20133, 225\u20136 lower limb plaster back slabs, full-length, 120 pharmacokinetics of, 182 lumbar spinal nerve blocks, 157, 160 pump failure, 189 lycra orthoses, 113 therapeutic effects of, 186\u20139 lyrica. See pregabalin trial dose, 184\u20135 intrathecal baclofen (ITB) pumps Malleolock ankle brace, 121, 122 CSF leakage from, 190 marijuana. See cannabis dosage adjustments, 186, 187, 188 Marinol. See dronabinol failure of, 189 measurement scales. See spasticity measurement scales; implant infection, 190 implant surgery, 185 speci\ufb01c scale pediatric use, 225\u20136 medial popliteal nerve blocks, 151\u20132, 154, 155 re\ufb01lls, 186, 187, 188 medial reticulospinal tract, 13\u201314 types of, 190 median neurotomy, 196, 197\u20138 intrathecal chemical rhizotomies, 202\u20133 medical history-taking, in seating assessment, 100 intrathecal nerve blocks, 7, 161\u20132 medium-latency response (MLR), 50 complications, 162 Medtronic SynchroMed\u00a9 pumps, 186, 187, 188, 190 indications, 161, 202\u20133 microDREZotomy (MDT), 203\u20134, 205\u20136, 207, 208, 209 procedures, 161\u20132 mobility limitations, 4 therapeutic effect of, 161\u20132 irradiation, re\ufb02ex, 16, 17 surgical management and, 209\u201311 modi\ufb01ed Ashworth scale joint stabilization, in children, 233 level of measurement, 66\u20137 ketazolam, 139 recommendations, 68\u20139, 76 knee ankle foot orthosis (KAFO), 121, 123\u20134, 125 reliability of, 67\u20138 motor control, descending pathways in, pathophysiology of, 10\u201311, 12 motor function, effect of peripheral neurotomies on, 197\u20138 motor learning, 87\u20138, 89, 90\u20131 targeted, orthoses for, 115","248 Index motor point injections, 157\u20139 in combined modality therapy, 92 complications, 160 orthoses for, 115 gastrosoleus muscles, 151\u20132, 158 to prevent contractures, 89\u201390, 91 hip adductors, 158 muscle weakness, botulinum toxin-related, 170 hip \ufb02exors, 158\u20139 musculocutaneous nerve block, 157 intramuscular alcohol wash in, 157\u20138 musculocutaneous neurotomy, 196, 197 versus nerve blocks, 157 myelotomy, longitudinal, 203 pediatric use of, 223\u20134 Myobloc\u00ae, 166\u20137 myometer, 72 motricity index, 133 myostatic contractures, 214, 218\u201319 movement. See also gait nabilone, 143 abnormal, orthotic prevention of, 114 natural reciprocal inhibition, 43 normal nausea, botulinum toxin-related, 170 needle placement, for nerve blocks, 153\u20134 Bobath concept of, 113 neonates, seating systems for, 108\u20139 orthotic promotion of, 114 nerve blocks, 7 M-response, 75 multidisciplinary care. See combined modality therapy alcohol. See alcohol nerve blocks multiple sclerosis, intrathecal baclofen for, 186\u20137 complications of, 160 muscle activation, tonic stretch re\ufb02exes during, 23\u20135 diagnostic use, 152 muscle activity, unnecessary, elimination of, 87 dosage and concentration, 159\u201360 muscle belly vibration, electrophysiologic studies of, 40, 41, intrathecal. See intrathecal nerve blocks 49\u201350 lumbar spinal, 157, 160 muscle contractions, as associated reactions, 3\u20134 medial popliteal, 151\u20132, 154, 155 muscle growth, in children with cerebral palsy, 215, 220, 225 versus motor point injections, 157 muscle length musculocutaneous, 157 immobilization and, 26\u20137, 90 needle placement, 153\u20134 posture and, 90\u20131 obturator, 152, 154\u20136, 157 muscle lengthening techniques, 90, 208\u20139, 215 open, 153 in children, 232\u20133 pediatric use, 223\u20134 muscle overactivity phenol. See phenol nerve blocks de\ufb01nition of, 79 procedure, 153\u20139 peripheral causes of, 132 sciatic, 157 voluntary, versus spasticity, 81\u20132, 83 therapeutic effects of, 159, 160 muscle resonant frequency measurement, 219, 228 for upper limb muscle spasticity, 152 muscle spasms neuro-ablative procedures, 193\u2013203, 209 characteristic features of, 3 NeuroBloc\u00ae, 166\u20137, 168, 176 effects of intrathecal baclofen on, 182 neurolytic agents. See also chemical neurolysis; speci\ufb01c extensor. See extensor spasms \ufb02exor. See \ufb02exor spasms agent frequency scale, 134 dosage and concentration, 159\u201360 muscle stiffness pharmacology, 152\u20133 in children, 214, 219, 228 side effects of, 160 immobilization and, 26\u20137, 90 neuropharmacology, 39, 52. See also pharmacological physiotherapy techniques for, 89\u201391 thixotropic, 28 therapy muscle tone neurophysiological approaches, to spasticity measurement, clinical testing of, 17\u201318 loss of, after intrathecal blocks, 162 74\u20136 muscle torque, measurement of, 219 neurostimulation procedures, 193 muscle training, 87\u20138, 89 neurotomy. See peripheral neurotomies; speci\ufb01c technique nine hole peg test, 133, 134","Index 249 nociceptive re\ufb02exes, 16, 28. See also speci\ufb01c re\ufb02ex parapyramidal tracts nonreciprocal inhibition, electrophysiologic studies of, inhibitory area in, 11 motor pathways in, 11 43\u20134, 45 disruption of, 11, 14 North American Taskforce, de\ufb01nitions, 79, 82 Nottingham Health Pro\ufb01le, 133 Parawalker, 124 noxious stimuli, reduction of, in seating, 105 partial posterior rhizotomy, 200 nursing problems, 5 participation restriction, de\ufb01nition of, 79 passive motion obturator nerve blocks, 152, 154\u20136, 157 obturator neurotomy, 194, 195, 224 antispastic agents and, 131 open nerve blocks, 153 resistance to, quanti\ufb01cation of, 65, 73, 84 Ortholen, 121 passive stiffness, de\ufb01nition of, 79 orthopaedic surgery, 208, 209 patient compliance, with orthoses, 119 patient education, 5 in children, 226, 232\u20133 pharmacological therapy, 133 orthoses, 113. See also speci\ufb01c orthosis patient selection chemical neurolysis, 151 aim of, 113, 114, 115 intrathecal baclofen, 183\u20135 assessment for, 114, 117, 119, 129 orthoses, 116, 117\u201319, 120 botulinum toxin combined with, 118, 125, 171 pediatric, 220 classi\ufb01cation of, 121 peripheral neurotomies, 196 in combined modality therapy, 91, 92, 93, 223 pharmacological therapy, 133 contraindications to, 118 role of physiotherapy in, 92 de\ufb01nition of, 113 selective dorsal rhizotomy, 225 design of, 115\u201317, 129 patient transfer, to seating system, 106 patient compliance with, 119 pediatric spasticity, 214 patient selection for, 116, 117\u201319, 120 botulinum toxin for, 174, 215, 219, 223, 224, 226\u20137, 229, pediatric use, 113, 120\u20131, 223 plastic versus metal, 116\u201317, 129 232 seating, 102, 114, 124 casting for, 223, 229\u201330 sensory element of, 113 causes of, 214, 215 simulating effect of, 117 chemical neurolysis for, 223\u20134 timing of use, 120 versus contractures, 214, 215\u201317 types of, 121\u20138 gait analysis, 219 Orthotics Research and Locomotor Assessment Unit growth and, 82\u20134, 215, 220, 225 intrathecal baclofen for, 188\u20139, 222\u20133, 225\u20136 (ORLAU), video vector technique, 73\u20134 management of, 219\u201333 orthotist, role of, 5\u20137 osteotomies, 209, 233 classi\ufb01cation of, 220\u20131 outcome measurement, 5 failure of, 220 indications for, 220 pediatric, 220 measurement of, 217\u201319, 220 pharmacological therapy, 133\u20134 multidisciplinary care for, 221, 224, 233\u20134 muscle lengthening for, 90\u20131 pain, 4\u20135 muscle stiffness and, 214, 219, 228 baclofen for, 181\u20132 muscle training for, 87, 88\u20139 at botulinum toxin injection site, 170 orthoses for, 113, 115, 120\u20131, 223 in children with spasticity, 222, 231\u20132 osteotomies for, 209 gate control theory of, 193 pain in, 222, 231\u20132 neurolytic agent-induced, 160 pathology of, 214\u201316, 217, 218 peripheral neurotomies for, 196, 224 pain assessment scales, 135 pharmacological management, 221\u20133 paraplegia-in-extension, 15, 33 paraplegia-in-\ufb02exion, 15, 33","250 Index pediatric spasticity (cont.) plantar response, extensor, 31, 32 seating systems, 108\u20139 plaster casting, 119\u201320 selective dorsal rhizotomy for, 224\u20135 plasticity, 15 surgical management, 93, 200\u20131, 202, 209\u201311, 226, plateau potentials, 47\u20138 232\u20133 polypropylene orthoses, 121\u20132, 123, 128 polysynaptic excitatory pathways, electrophysiologic pendulum test, 71\u20132, 76 percussion, tendon, 16\u201317 studies of, 49\u201351 percutaneous thermorhizotomies, 202\u20133 polysynaptic excitatory postsynaptic potentials peripheral neurotomies, 194\u20138. See also speci\ufb01c (pEPSP), 15 technique pommels, seating support with, 102, 109 in children, 196, 224 positioning, 99. See also seating indications, 196, 209 lower limbs, 194\u20135, 196, 197, 199 orthotics for, 114 therapeutic effect of, 197\u20138, 199 principles of, 100\u20136 upper limbs, 196\u20138 positive support reaction, 38, 118 persistent inward currents (PICs), 47\u20138 posterior rhizotomy, 198 pharmacological therapy, 131. See also antispastic agents; functional, 200 partial, 200 speci\ufb01c drug sectorial, 199 clinical ef\ufb01cacy, 136 selective, 198\u20139 goals of, 132 therapeutic results, 200\u20132 management strategy, 132\u20133 postural stabilization, in seating, 104 muscle overactivity and, 131\u20132 posture outcome measures, 133\u20134 dystonia and, 37 patient selection for, 133 extensor spasms and, 32\u20133 pediatric use, 221\u20133 hemiplegic. See hemiplegic posture role of physiotherapy in, 92\u20133 horseback riding, 106 phasic stretch re\ufb02exes, 16\u201317 muscle length and, 90\u20131 phenol nonreciprocal inhibition and, 45 aqueous solutions, 153, 159 seated. See seating dosage and concentration, 159 spasticity measurement and, 69 in drug combinations, 133 standing, 106 in glycerine, 153, 161\u20132 tonic stretch re\ufb02exes and, 19\u201320 intramuscular wash, 157\u20138 powered biomechanical systems, for spasticity intrathecal, 161\u20132, 184 pharmacology, 152\u20133 measurement, 72\u20133 side effects of, 160, 162 practice of muscle skills, 87\u20139, 90\u20131 phenol nerve blocks, 7 precentral cortical stimulation, 193 indications, 132\u20133 pregabalin, 144 pediatric use, 223\u20134 pressure reduction therapeutic effects of, 159, 160 physical examination, in seating assessment, in orthoses, 115 in seating systems, 107 100 presynaptic inhibition, evaluation of, 40\u20132 Physician Rating Scales, for gait analysis, 219 pronator teres contractures, 228\u20139 physiotherapist, role of, 5\u20137, 92\u20133 proprioception, de\ufb01nition of, 16 physiotherapy, 79 proprioceptive re\ufb02exes, 16 psoas major, motor point injections of, 158\u20139 interventions, 85\u201393 pumps. See intrathecal baclofen (ITB) pumps in multidisciplinary care, 92\u20133 pyramidal tracts in seating support, 100 motor pathways in, 11 spasticity assessment in, 84\u20135 Pierrot-Deseilligny technique, 43, 44 disruption of, 11 plantar response linked to, 31, 32","Index 251 quadriceps spasticity, orthotic correction for, 116 reduction of noxious stimuli, 105 quality of life sustained muscle stretch in, 100\u20131 for transportation, 109 assessment of, 133, 135 trunk orientation in, 102\u20133 effects of intrathecal baclofen on, 183 seating orthosis, 102, 114, 124 quiet zones, 118 seating simulator, assessment using, 100 seating systems radiofrequency rhizotomy, percutaneous, 202\u20133 adjustable, 107\u20138, 109 range of motion arm restraints in, 103\u20134 back rests in, 102\u20133 orthotic promotion of, 114\u201315 choosing, 108\u20139 restriction of, pathophysiology of, 2 comfort of, 105, 107 testing of, 135, 217\u201319 custom moulded, 109 rash, botulinum toxin-related, 170 design of, 106\u20138 rat, alpha motor neurone excitability in, 47, 48 dynamic, 107, 109 reciprocal gait orthosis, 124 ergonomics and, 106 reciprocal inhibition positioning in, 106 electrophysiologic studies of, 42, 43 pressure reduction in, 107 impairment of, co-contraction caused by, 34\u20135, 43 reduction of unnecessary upper limb activity, 104\u20135 recurrent (Renshaw) inhibition, electrophysiologic studies restraints in, 103\u20134, 106, 107 shear forces in, 107 of, 45\u20136, 47 strength and durability of, 107 re\ufb02ex irradiation, 16, 17 success of, evaluating, 108 Relaxation Index, 71 sectorial posterior rhizotomy, 199 \u2018release\u2019 effect, 15 selective dorsal rhizotomy (SDR) Renshaw cell activity, electrophysiologic studies of, 45\u20136, 47 in children, 224\u20135 resonant frequency measurements, 219, 228 physiotherapy in, 92\u20133 restraints, in seating systems, 107 selective posterior rhizotomy, 198\u20139 reticulospinal tract, 13\u201314 self-management, 5 rhizotomy, 7 serial casting, 119\u201320 in children, 223 versus intrathecal baclofen, 184 in combined modality therapy, 92 intrathecal chemical, 202\u20133 to prevent contractures, 91 percutaneous radiofrequency, 202\u20133 servomechanism theory, 233 posterior. See posterior rhizotomy shear forces selective dorsal. See selective dorsal rhizotomy (SDR) in orthoses, 115 rigidity, 118 in seating systems, 107 rotational osteotomies, 233 shoes R1\/R2 testing, 218 design of, 116\u201317 rubrospinal tract, 13 insoles in, 114, 118, 121, 122\u20133 orthotic adaptations to, 116, 121 SAM system, 106 Short Form 36 Questionnaire, 133 sativex, 143 short-latency response (SLR), 50 sciatic nerve block, 157 shoulder, hemiplegic scissoring gait, obturator nerve blocks for, 152 botulinum toxin for, 175, 228\u20139 scoring systems, for gait analysis, 219 orthotic management of, 126\u20137, 128 seat cushions, 107 shunting, 118 seating, 99 Silfverskiold test, 217\u201318 silicone orthoses, 129 alternative postures for, 105\u20136 single event multilevel surgery (SEMLS), 93 clinical assessment, 100 dif\ufb01culty with, 4 hip integrity maintenance in, 101\u20132, 103, 120\u20131 postural stabilization in, 104 principles of, 100\u20136","252 Index sinusoidal stretch, 84, 85 spinal cord sitting braces, 124 descending pathways in, 12, 13\u201314 skill, lack of inhibitory versus excitatory tracts in, 14 stimulation of, 193 muscle overactivity caused by, 81\u20132, 83, 89 muscle training to overcome, 87\u20139 spinal cord injury (SCI), intrathecal baclofen for, 187\u20138 spinal cord lesions orthoses for, 115 soft tissue changes. See also contractures complete versus incomplete, 15 spasticity caused by, versus cerebral lesions, 14\u201315 biomechanical hypertonia caused by, 26\u20137 spinal inhibitory mechanisms, electrophysiological studies characteristic features of, 2\u20133 prevention of, 89\u201391 of, 38 stretch re\ufb02ex hyperexcitability and, 25 spinal segmental re\ufb02exes. See also speci\ufb01c re\ufb02ex soft tissue injury, from nerve blocks, 160 soleus H-re\ufb02ex recovery curve, 51 brainstem areas controlling, 11, 12, 14 soleus shortening, 217\u201318 classi\ufb01cation of, 16 somatosensory cortex, 12 electrophysiological studies of, 38 plasticity of, 15 evocation of, 74\u20135 spastic catch, 2 excitability of, change in, 15\u201316 spasticity pathophysiology of, 16 with cerebral lesions, versus spinal cord lesions, spinal shock pathophysiology of, 15\u201316 14\u201315 presynaptic inhibition in, 41 characteristic features of, 2 splinting, 113 in children. See pediatric spasticity botulinum toxin combined with, 171 classi\ufb01cation of, 81 de\ufb01nition of, 113 de\ufb01nition of, 1, 9\u201310, 53, 64, 79, 80, 82, 214 standing posture, 106 as determinant of activity limitations, 80\u20131 static range of motion testing, 217\u20139 effect of intrathecal baclofen on, 182 static tonic stretch re\ufb02exes, 21\u20133, 50 effect of pathology on, 82\u20134 stepping generator, 28, 32 functional bene\ufb01ts of, 131, 159, 219\u201320 strength-training programs, 87, 88 management approach to, 5\u20136, 7 stretching maturation factors in, 82\u20134 contracture prevention with, 2, 101 neurophysiology of, 9 effect on dystonia, 37 versus other impairments, 81\u20132, 83, 214 repeated, effect on tonic stretch re\ufb02exes, 20, 37, 69 spasticity measurement, 64 in seating support, 100\u20131 approaches to, 65 stretch re\ufb02ex, in range of motion testing, 218\u201319 barriers to, 64 stretch re\ufb02ex arc, 16 biomechanical approaches to, 71\u20134, 76 stretch re\ufb02ex hyperexcitability versus co-contraction, 35, 36 indirect, 73\u20134, 76 physiological mechanisms underlying, 24\u20135 before botulinum toxin use, 167\u20138 stride length test, 133 in children, 217\u20139 supplementary motor area (SMA), 12 levels of, 65, 66 surgical management, 7, 193. See also speci\ufb01c technique neurophysiological approaches to, 74\u20136 in children, 200\u20131, 202, 209\u201311 in physiotherapy, 84\u20135 in combined modality therapy, 200, 201 seating system evaluation and, 108 indications for, 209\u201310, 211 spasticity measurement scales, 66, 74. See also speci\ufb01c scale orthopaedic, 208, 209 requirements of, 65 personal adaptations, 200 spastic motor overactivity, 53 role of physiotherapy in, 92\u20133 treatment of, arguments against, 53\u20134 swallowing, dif\ufb01culty with, 4 spastic movement disorder, 52\u20134 Swedish knee brace, 116, 118, 119 spinal catheterization, for intrathecal baclofen, 185, 187, SynchroMed\u00ae pumps, 186, 187, 188, 190 189","Index 253 Tardieu method of assessment, 69\u201370 trunk orientation, in seating, 102\u20133 versus Ashworth scales, 85 twisters, 124 level of measurement, 70 recommendations, 70, 76 ulnar neurotomy, 197\u20138 reliability of, 70, 71, 85, 86 ultrasound guidance, for botulinum toxin injection, 169 unskilled performance tendon jerks, 74\u20135, 84, 85 tendon percussion, 16\u201317 muscle overactivity in, 81\u20132, 83, 89 tendon re\ufb02ex (T re\ufb02ex), versus H re\ufb02ex, 38\u201340 muscle training to overcome, 87\u20139 tendon re\ufb02ex irradiation, 16, 17 tendon transfer, 209 orthoses for, 115 tenotomies, 232 upper limb terazepam, 139 THC (delta-9-tetrahydroccabinol), 143\u20134 musculocutaneous nerve block in, 157 Therex pump, 190 peripheral neurotomies in, 196\u20138 thermorhizotomies, percutaneous, 202\u20133 upper limb activity thixotropy, 28 dexterity and strength testing, 134 tibialis anterior, \ufb02exor withdrawal re\ufb02exes of, unnecessary, reduction of, in seating systems, 104\u20135 upper limb muscle spasticity 30, 31 botulinum toxin for, 171\u20132, 174, 228\u20139 tibial neurotomy, 194\u20135, 196, 197, 199 nerve blocks for, 152 tilt table, weight bearing using, 106 upper limb restraints, in seating systems, 103\u20134 tizanidine, 141, 142\u20133 upper motor neurone(s), pathophysiology of, 10\u201311 upper motor neurone (UMN) syndrome clinical ef\ufb01cacy, 136, 142, 222 clinical consequences of, 4\u20135 dosage and administration, 142\u20133 de\ufb01nition of, 1, 9\u201310 mechanism of action, 13, 141, 222 management of pediatric use, 222 pharmacokinetics, 142 aims of, 5 side effects of, 143 approach to, 5\u20136, 7 toe clawing, botulinum toxin for, 175 negative phenomena of, 1, 2, 79 toileting, hip integrity and, 102 neuropharmacology of, 52 tone, de\ufb01nition of, 64, 79 pathophysiology of, 10, 14\u201315, 16, 214\u201317 tone intensity scale, 134 positive phenomena of, 1\u20132, 4, 9\u201310, 79 tonic ambulatory foot response. See positive support Valium. See diazepam reaction ventromedial reticular formation, 11 tonic stretch re\ufb02exes, 16, 17\u201321 vestibulospinal re\ufb02exes, in associated reactions, 34 vestibulospinal tract, 12\u201314 effect of repeated stretching on, 20, 37, 69 vibration, 40, 41, 49\u201350 length dependence of, 19\u201321, 22 video recording, in gait analysis, 219 during muscle activation, 23\u20135 video vector technique, 73\u20134 in normal subjects, 18 voluntary muscle overactivity, versus spasticity, 81\u20132, 83 pathophysiology of, 19 static, 21\u20133, 50 walking. See gait velocity dependence of, 19, 20\u20131, 22, 85 Wartenberg Pendulum Test, 71\u20132, 76 tonic vibration re\ufb02ex (TVR), 40, 41, 49 weight bearing, using tilt table, 106 transcutaneous electrical nerve stimulation wheelchairs. See also seating systems (TENS), 41, 160 powered versus manual, 104\u20135 transportation, seating for, 109 transport of, 109 traumatic brain injury (TBI), intrathecal baclofen windsweeping, 102, 103 wrist orthoses, 127\u20138 for, 188 tricyclic antidepressants, 160 Xeomin\u00ae, 166, 170, 176 triple \ufb02exion response, 28, 32 truncal spasticity, 4"]